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Acute Kidney Injury. 49 year old man was a single vehicle MVC in which he was ejected. His injuries include: Left temporal epidural hematoma Left hemo/pneumothorax Liver laceration Bilateral open compound femur fractures

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Acute Kidney Injury

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Acute kidney injury l.jpg

Acute Kidney Injury


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  • 49 year old man was a single vehicle MVC in which he was ejected. His injuries include:

    • Left temporal epidural hematoma

    • Left hemo/pneumothorax

    • Liver laceration

    • Bilateral open compound femur fractures

  • He is brought to the ICU postop after an urgent craniotomy for the epidural.

  • A chest tube is in place but the fractures are only splinted.


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  • 6 hours after admission, the nurse calls because the urine output has fallen.

  • On assessment, he is sedated and intubated with both legs in traction.

  • He is hemodynamically stable, BP 168/86, pulse 96, no vasopressors and afebrile.

  • There is about 200 mL of dark urine in the foley bag (emptied upon arrival to ICU).


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  • Is there a problem with the urine output?

  • The patient weighs about 75 kg and is known to have some renal insufficiency with a baseline creatinine of 200. Creatinine on admission was 305.

  • Is there a problem with the urine output?


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  • RIFLE Criteria

    • Risk

      • 1.5X increase in creatinine or UO < 0.5 ml/kg for 6 hours

    • Injury

      • 2X increase in creatinine or UO < 0.5 ml/kg for 12 hours

    • Failure

      • 3X increase in creatinine or UO < 0.5 ml/kg for 24 hours or anuria for 12 hours

    • Loss

      • Complete loss of function for more than 4 weeks

    • ESRD

      • Complete loss of function for more than 3 months


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  • Where is the patient in the RIFLE criteria?

  • List some possible causes for the renal dysfunction in this case.

    • Volume depletion

    • Radiocontrast dye

    • Myoglobinuria

    • Acute on chronic renal insufficiency


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  • Categorize the different causes of acute renal insufficiency.

    • Prerenal: volume depletion and relative hypotension

    • Vascular: Consider vasculitis, TTP, nephrosclerosis, renal artery stenosis

    • Glomerular: Consider the nephritic and nephrotic syndromes

    • Tubular/interstitial: Consider ATN, drugs, PCKD, myeloma, autoimmune disorders

    • Obstructive: Consider prostate disease, stones, metastatic cancer


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  • What are the most likely causes in hospitalized patients?

    • ATN (45%)

    • Prerenal (21%)

    • Acute on chronic kidney disease (13%)

    • Obstruction (10%)

    • Glomerulonephritis or vasculitis (4%)

    • Acute interstitial nephritis (2%)

    • Atheroemboli (1%)


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  • 6 hours later, the patient’s urine output has been a total of 350 mL since admission. The creatinine has risen to 455.

  • What RIFLE criteria is the patient now?

  • What investigations could be ordered to identify the cause of the acute kidney injury?

  • What are the implications on morbidity and mortality when renal failure occurs in the ICU?


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  • The urine sodium is 125 mmol/L, urine osmolarity is 247 mOsm/L, serum osmolality is 315 mOsm/L, CK 98035, and urine myoglobin 15035.

  • It is now 24 hours since admission and there has only been another 100 mL of urine with no urine for the last 12 hours.

  • What is the RIFLE criteria now?


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  • What treatments could have been started to mitigate the development of acute kidney failure?

  • What are the indications for renal replacement therapy in the critical care setting?

  • How do you choose between continuous versus intermittent hemodialysis?


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  • After inserting a femoral dialysis catheter, the patient is started on hemodialysis.

  • He is currently has a MAP of 65 requiring levophed 12 ug/min with a FiO2 of 85% (increased since starting fluid boluses.

  • Will this patient tolerate an intermittent run of dialysis? Why or why not?

  • How does hemodialysis work?


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  • What are the different modes of continuous renal replacement?


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Questions??


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